---

AETCOM – Patient Counselling in Acute Epiglottitis (5 marks)

What to Explain to the Patient/Guardian

---

1. Necessity of Conservative Management

• Acute epiglottitis is a serious, potentially life-threatening infection causing swelling of the epiglottis (the flap of tissue that covers the windpipe).
• Initial conservative management includes IV antibiotics (commonly ceftriaxone or augmentin), corticosteroids to reduce swelling, humidified oxygen, and keeping the patient calm and upright (sitting, leaning forward — the "tripod" position).
• The patient must remain strictly monitored in a hospital setting, ideally in an ICU or high-dependency unit, because the airway can deteriorate without warning.
• Explain that disturbing the patient (blood draws, lying flat, throat examination without preparation) can trigger total airway obstruction — so full cooperation is essential.

---

2. Necessity of Intubation / Tracheostomy if Conservative Management Fails

• If breathing worsens despite medical treatment, securing the airway becomes mandatory — this is not optional.
• Endotracheal intubation is the first-line airway intervention and is performed in the operating theatre under inhalation anaesthesia with a surgeon on standby.
• If intubation is not possible (due to severe supraglottic swelling and distorted anatomy), an emergency tracheostomy (surgical airway through the neck) will be performed to bypass the obstruction and save the patient's life.
• The family/patient must give informed consent for both procedures in advance, as there may be no time to obtain consent once deterioration begins.
• These procedures carry their own risks (bleeding, infection, voice change, tracheal injury), which must be disclosed.

---

3. Possibility of Worsening — Even Death — Before, During, or After the Procedure

• Acute epiglottitis carries a real risk of sudden, fatal airway obstruction even in patients who appear stable.
• The patient or family must understand that deterioration can be rapid and unpredictable — from mild stridor to complete obstruction within minutes.
• Even with the best care, death can occur:
  • Before the procedure — if the airway closes before the team can act
  • During the procedure — due to laryngospasm, failed intubation, or cardiac arrest under anaesthesia
  • After the procedure — due to complications like aspiration, secondary pneumonia, or sepsis
• This honest disclosure is essential for informed consent and allows the family to prepare.
• Reassure them that the medical team will make every effort, and that outcomes are generally good when treatment begins early.

---

Communication Approach (AETCOM Principles)

---

— Barash Clinical Anesthesia 9e; Rosen's Emergency Medicine 10e

Clinical Features / Diagnosis of Acute Epiglottitis

---

Classic Presentation — The "4 D's"

---

History

• Acute, rapid onset — hours, not days
• High fever (typically >38.5°C)
• Severe sore throat out of proportion to pharyngeal findings on exam
• No cough (important distinguishing feature from croup)
• Preceding upper respiratory symptoms usually absent

---

Clinical Signs on Examination

• Tripod / sniffing position — patient sits upright, leans forward, jaw jutted out, neck extended — this maximises airway patency and is almost pathognomonic
• Drooling (cannot swallow secretions)
• Toxic, anxious appearance
• Inspiratory stridor (may be absent early)
• Suprasternal / intercostal retractions in severe cases
• Cyanosis — late, pre-terminal sign
• No cough, no hoarseness (unlike croup/laryngitis)

⚠️ Do NOT attempt direct throat examination in the ED or clinic without full airway readiness — stimulating the hypopharynx can trigger total laryngospasm and death.

---

Investigations

---

Radiological Sign

---

Differential Diagnosis at a Glance

---

— Rosen's Emergency Medicine 10e; Barash Clinical Anesthesia 9e

Medical Tracheotomy — Complete Overview

---

Terminology

---

Indications

• Acute epiglottitis, Ludwig's angina, head & neck tumours, bilateral vocal cord paralysis, severe facial/neck trauma, foreign body, anaphylaxis

• Neurological conditions — stroke, GBS, MND, cervical spine injury
• Copious pulmonary secretions requiring repeated suctioning

• When intubation is expected to last >7–10 days (reduces subglottic trauma and patient discomfort)

• Pulmonary insufficiency — reduces anatomical dead space by ~150 mL
• Facilitates weaning from ventilator

• Severe obstructive sleep apnoea refractory to CPAP
• Recurrent aspiration with failed conservative management

---

Recognising the Need — Signs of Airway Obstruction

Intervene early rather than wait for late or danger signs.

---

Surgical Technique — Open Tracheotomy

1. Skin incision — Horizontal or vertical midline incision, 2 cm below the cricoid cartilage
2. Subcutaneous dissection — Divide subcutaneous tissue and superficial cervical fascia
3. Strap muscle separation — Retract sternohyoid and sternothyroid muscles laterally at the midline (do not cut)
4. Thyroid isthmus — Retract superiorly or divide between clamps and ligate if it overlies the trachea
5. Pretracheal fascia — Dissect and expose anterior tracheal wall
6. Tracheal incision — Between the 2nd and 3rd tracheal rings (never the 1st ring — risks subglottic stenosis)
   • Options: vertical incision, horizontal incision, window/Bjork flap
7. Stay sutures — Placed through tracheal rings on each side; labeled LEFT/RIGHT and taped to chest for emergency re-access
8. Partial withdrawal of ETT — Pull ET tube tip just superior to the tracheotomy site before inserting trach tube
9. Tracheotomy tube insertion — Insert with obturator, inflate cuff, confirm with capnography and bilateral auscultation
10. Secure tube — Suture flange to skin + trach ties (one–two fingers should fit under ties)

---

Operative Image

---

Bjork Flap Technique

---

Postoperative Care

• Chest X-ray (AP + lateral) to confirm tube position, exclude pneumothorax and pneumomediastinum
• Do not change outer tube for 3–4 days (tract not yet formed — risk of false passage)
• Frequent inner cannula cleaning and suctioning
• Stay sutures remain accessible for at least 7 days in case of accidental decannulation
• Humidified oxygen/air to prevent crusting of secretions

---

Complications

---

Types of Tracheotomy Tubes

---

— Cummings Otolaryngology 7e; K.J. Lee's Essential Otolaryngology

acute epiglottitis cherry red swollen epiglottis endoscopy laryngoscopy

Acute Epiglottitis — Full Overview

---

Definition

---

Epidemiology

• Pre-vaccine era: primarily affected children aged 2–7 years
• Post-Hib vaccine era (post-1985): incidence in children has fallen dramatically; disease now relatively more common in older children and adults (adults peak at 20–40 years)
• Incidence: ~10–40 cases per million in the USA

---

Etiology

---

Pathophysiology

Bacterial invasion of supraglottic mucosa
        ↓
Cellulitis → Inflammation & oedema of epiglottis + 
aryepiglottic folds + arytenoids
        ↓
Structures protrude DOWNWARD over the glottic opening
        ↓
Reduced upper airway calibre → turbulent inspiratory airflow (STRIDOR)
        ↓
Epiglottis acts as a BALL VALVE:
  - Obstructs airflow during INSPIRATION
  - Permits exhalation
        ↓
Worsening hypoxia → respiratory failure → DEATH

---

Clinical Features — The 4 D's

• Abrupt onset of high fever (>39°C)
• Severe sore throat out of proportion to physical findings
• Toxic, anxious appearance
• Tripod/sniffing position — sitting upright, leaning forward, jaw jutted, neck extended ← near-pathognomonic
• No cough (key differentiator from croup)
• Anterior neck tenderness on palpation
• Cyanosis — late, pre-terminal sign

---

Investigations

⚠️ Never perform direct throat examination in the ED in an unsecured patient — may trigger total laryngospasm.

---

Management

Step 1 — Immediate Priorities (ABC)

• Do NOT lay patient flat — maintain sitting/tripod position
• Minimise disturbance — no IV lines, blood draws, or throat exam until airway is secured
• Administer humidified oxygen by mask if tolerated (do not force)
• Call anaesthesiology + ENT + ICU simultaneously
• Transport to operating theatre for controlled airway management

Step 2 — Airway Management

• Remain intubated for 3–5 days while antibiotics reduce oedema
• Extubate when an air leak develops around the tube (indicates reduced swelling)

Step 3 — Medical Management

Step 4 — Admission

• All patients → ICU or HDU regardless of initial severity

---

Epiglottitis vs Croup — Key Differences

---

Complications

• Total airway obstruction → respiratory arrest → death
• Bacteraemia / septicaemia
• Epiglottic abscess (especially adolescents)
• Necrotising epiglottitis (immunocompromised)
• Pulmonary oedema post-obstruction
• Subglottic stenosis (after prolonged intubation)

---

— Rosen's Emergency Medicine 10e; Tintinalli's Emergency Medicine 9e; Barash Clinical Anesthesia 9e

Surgical Management of Acute Epiglottitis

---

Guiding Principle

---

Decision Algorithm

SUSPECTED ACUTE EPIGLOTTITIS
           ↓
  Keep patient calm, upright (tripod)
  Humidified O₂ by mask if tolerated
  Call: Anaesthesiology + ENT + ICU
           ↓
     ┌─────────────────────────────────┐
     │         ASSESS SEVERITY         │
     └─────────────────────────────────┘
           ↓                    ↓
     CHILD / Severe          ADULT / Stable
   airway compromise         mild-moderate
           ↓                    ↓
    Transfer directly       ICU admission
     to OPERATING            IV antibiotics
       THEATRE               IV steroids
           ↓                  Monitor closely
   Inhalation induction            ↓
    (sevoflurane, O₂)        Worsening? → OR
           ↓
    Oral intubation
   (tube 0.5mm smaller)
           ↓
   FAILS → Rigid bronchoscopy
           ↓
   FAILS → Surgical airway

---

Step-by-Step Surgical Airway Management

1. Pre-operative Preparation (in OR)

• Patient kept sitting upright in the OR while monitoring is placed
• Pulse oximetry + capnography + precordial stethoscope
• OR prepared with: laryngoscope, video laryngoscope, rigid bronchoscope, surgical tracheostomy set — all immediately available
• One parent may remain in the OR to keep child calm
• Do NOT give IV access or perform venepuncture before induction — crying worsens stridor and can trigger total obstruction

2. Anaesthetic Induction

• Inhalation induction with sevoflurane + oxygen (increasing concentrations slowly)
• Child may sit in anaesthesiologist's lap during induction
• Spontaneous breathing maintained throughout — muscle relaxants avoided until airway is secured
• Once consciousness is lost: IV access obtained, patient lowered supine

3. Laryngoscopy and Intubation

• Video laryngoscopy preferred — allows shared view of distorted anatomy among the whole team
• Oral endotracheal intubation performed without muscle relaxants
• ETT 0.5 mm smaller than usual (to accommodate swollen supraglottic structures)
• Stylet often needed
• If glottis cannot be visualised: ask assistant to compress the chest → air bubble rises from glottis → aim for it

4. Failed Intubation Protocol

5. Surgical Airway Options

• Landmark: cricothyroid membrane (between thyroid & cricoid cartilage)
• Vertical skin incision → horizontal stab through membrane → insert cuffed tube/airway catheter
• Fastest emergency surgical airway
• Must be converted to tracheostomy within 24–72 hrs (risk of subglottic stenosis)

• 14G angiocatheter through cricothyroid membrane
• Attach to jet ventilator or 3mL syringe barrel + bag-valve-mask
• Temporising only — buys 30–45 minutes of oxygenation

• Preferred when personnel skilled in difficult airways are not available
• Creates airway below the obstruction — most definitive
• Between 2nd–3rd tracheal rings
• Larger, more stable airway; better for prolonged ventilation

---

Post-Intubation Management

---

Adult vs Child — Key Difference

---

— Barash Clinical Anesthesia 9e; Miller's Anesthesia 10e; Rosen's Emergency Medicine 10e; Tintinalli's Emergency Medicine 9e